Rural doctors up against size, cost disadvantage

Dr. Adrian Billings (center, standing) visits with a family at a community health fair in Marathon last year. The family was waiting for a health screening at the booth Billings and his colleague set up.

EDITOR’S NOTE: Today’s stories are part of the Denton Record-Chronicle’s ongoing look at the health care reform law. The newspaper’s six-day, 14-story series was published in late February and early March — a joint effort between the newspaper and graduate students from the UNT Mayborn School of Journalism. Visit DentonRC.com/local-news/health.

ALPINE — At 2 a.m. on a Sunday night, Dr. Adrian Billings’ cellphone rang. Working as the only doctor at Pearce Clinic had been a time-suck for him ever since he moved to the Big Bend town of Alpine.

His labor and delivery nurse told him one of his patients was about to deliver a nine-week-premature baby, so he left his wife and three young boys sleeping and drove to Big Bend Regional Medical Center a mile outside town.

The closest neonatologist he would need to care for the baby was 150 miles away in Odessa. And the only way to get there in time was on a twin-engine medevac plane at Alpine’s local airstrip across from the hospital.

He called the obstetrician and the neonatologist in Odessa for help, but neither would risk the chance of the mother delivering on the airplane or send a neonatal team to him before the child was delivered. Daylight would creep over the nearby mountains before he convinced the airplane crew to fly the mother to Odessa — and it was only after he slowed her contractions down to one every 10 minutes and agreed to monitor her on the plane.

They got there in time to deliver the baby safely at the Odessa hospital, and Billings later treated the flight crew to a celebratory meal at Red Lobster before flying back to Alpine. He skipped showering once he got back that afternoon and drove straight to Pearce Clinic to try to keep up with his Monday appointments.

Billings, 40, said he was the last of the private practice herd to move to Alpine more than four years ago. But he saw the writing on the wall as health care reform legislation began to increase funding toward federal programs that recruit and retain primary care physicians in rural areas while decreasing reimbursements to private practices.

That’s why he sold his private practice to Cactus Health Services, a federally qualified health center based out of Sanderson. Federal money had brought Billings to Alpine, and now it was keeping him there.

He could be like the small-town doctor who had delivered him and saw him grow up in his hometown of Del Rio. By contrast, many of the physicians Billings graduated with got jobs with hospitals or other group practices.

“They were all becoming employed, because it’s easy,” Billings said. “You don’t have any startup costs. It’s safe; it’s not a gamble.”

But Billings’ advantage was that he left residency without any medical school debt. Instead, he owed time in a medically underserved area, a requirement of his federal loan from the National Health Service Corps.

Rural access

Created in 1972 as a part of the U.S. Department of Health and Human Services, the incentive program offers loan repayment and scholarships to medical school students in exchange for service in areas that have shortages of health care personnel and services.

Texas has more than 300 areas, including areas in Dallas and Denton counties, considered medically underserved for primary care, as designated by the Health Resources and Services Administration.

That gap doesn’t hurt just primary care for rural patients. Fewer than half of Texas accident victims in rural areas made it to any hospital — let alone a trauma center — within 60 minutes in 2009, the most recent data available, according to the National Highway Traffic Safety Administration.

James Swartz, president and CEO of CareFlite, grew up on a Texas farm and saw early attempts at emergency care.

“EMS was provided by the local undertaker,” Swartz said.

CareFlite is a nonprofit ground and air ambulance service sponsored in part by five North Texas hospital systems and by memberships. Krugerville and Cross Roads enrolled as cities to provide the service to the entire community. Some water districts also provide the service by charging a small fee on the monthly water bill, Swartz said.

Membership isn’t insurance, but those participating in the system save thousands of dollars when a family member needs that transportation.

CareFlite is a provider in five 911 systems in the region, Swartz said, so the question of access for rural areas is one their system often considers.

Last year, the company provided more than 50,000 air and ground transports, he said.

The National Health Service Corps is reasonably effective in getting doctors into medically underserved areas, particularly in short-term stints, said Dr. Howard Rabinowitz, an expert in rural health manpower at Thomas Jefferson University in Pennsylvania.

So the government is boosting the funding. The Patient Protection and Affordable Care Act of 2010 appropriated more than $530 million for the program this fiscal year. The following years’ funding increases in increments of almost $200 million, and in 2015 funding will be more than $1 billion.

In October, Health and Human Services Secretary Kathleen Sebelius announced the program had awarded nearly $900 million in loan repayments and awards because of investments from the health care law and the American Recovery and Reinvestment Act, bringing the total number of health care providers in the program to more than 10,000, up from 3,600 in 2008.

Billings owed four years’ work at Pearce Clinic for his loan repayment. Running a practice out-of-pocket became a daily stress test.

Dr. Gary Floyd, executive vice president of medical affairs at JPS Health Network in Fort Worth, worked in a group pediatric practice 30 years ago. His group practice had one office manager come in once a week to file claims and paperwork.

The same practice today has five full-time employees who handle Medicaid and other insurance, Floyd said.

A rural medical home

Dr. Clifton Pearce opened Pearce Clinic as a family-run practice in 1986. His wife was also his nurse, and his mother worked as office manager. During Billings’ medical school days, he worked alongside Pearce a few times for training. But in April 2001, Pearce died when his single-engine plane crashed into a tree in Matagorda County on the way to a family Easter gathering.

Some Alpine residents asked the City Council to rename Brown Street, the clinic’s address, after Pearce. But it was council member Frank Yakubanski who saw to it that the terminal at the Alpine-Casparis Municipal Airport was named after the doctor.

His widow and mother still ran a small nursing operation out of the clinic when Billings came to back to work there in 2007. So with one office manager and a medical staff composed of a few nurses, one nurse practitioner and a sonographer that came in a couple days a week, Billings began working 12-hour days, seeing 25 patients a day. He would make morning and evening rounds at the hospital and also functioned as the medical director for Sul Ross State University.

For four years he would work those hours, spending 10 hours in the clinic, two hours making hospital runs, taking his hour for lunch at home to see his wife and kids, and always on call for any emergency — especially for deliveries, which make up a quarter of his practice.

Despite the strain it put on him, he was still protective of his clinic.

“Dr. Billings wasn’t an easy sell; it took some understanding and he needed to know and feel comfortable how the FQHC [federally qualified health centers] would operate, because you’re asking a doctor to give up his private practice, which he literally controls,” said Alex Gonzalez, executive director of Cactus Health Services.

But Billings needed the help. After a few days of negotiating, Gonzalez applied to the Health Resources and Services Administration for a change in scope to add a service site in Alpine.

It took six months for the merger to go through. In exchange for the control Billings gave up, he was instead getting triple the reimbursement from Medicare and Medicaid, free federal malpractice insurance, access to a plethora of government grants and enough capital to hire on a partner to cover his patient load. The catch was that he had to see everybody — insurance or no. That was nothing new to Billings.

“Even before when I was a private clinic, if we dropped any insurer, we wouldn’t be sustainable,” Billings said.

Almost 40 percent of his patients were on Medicare already, and the rest either had private insurance, Medicaid or none at all.

“Seeing a Medicare patient is less reimbursement than a privately insured patient, but we’ve got to include everybody because the population is such that we’re not Plano, where I can have an exclusive Blue Cross Blue Shield practice,” Billings said. “And in my morals and beliefs, it’s just not the right thing to do to exclude somebody.”

Physician shortages

A large troop of Tiger Cub Scouts surrounds the arcade game at Pizza Hut to watch dozens of aliens scream and splatter into mush as Billings’ oldest son, Blake, dishes out death with a blue toy pistol. Billings stands aside, observing the action with local chiropractor Beau Coggins, who runs a practice with his father in Alpine.

Billings presses both hands into his lower spine to show Coggins where he feels pain.

“It’s all that driving, man,” Coggins says. “You need to get in to see us.”

“Yeah, I know,” Billings replies.

Part of the merger requires Billings to make rounds 84 miles away in Sanderson and 70 miles away in Fort Stockton a couple days every other week.

His 1996 Jeep Grand Cherokee shows some wear, too, with two long cracks stretching across the windshield. But it probably looks better to his patients that he’s not driving a Mercedes, Billings said.

In deep West Texas, Alpine could seem isolated, but it’s a medical hub for the dozens of small towns in Brewster County and beyond. Big Bend Regional Medical Center not only serves as the critical access hospital for Alpine and Brewster County, but is responsible for an 18,600-square-mile area stretching from Sanderson to Van Horn to Presidio and Big Bend National Park.

That’s three times the square mileage of Brewster County, the largest county in Texas. And with the mileage comes nearly three times the patient load.

About 25,000 patients live in that area, Billings said.

“Now, they don’t all get their health care here with us, but a vast majority of them do,” he said. “So if you think of being five health care providers, we’re certainly short with that 1-to-2,000 ratio.”

Billings is one of only five primary care doctors who practice and live in Alpine, and like many rural doctors, they typically take on a patient load of 2,000 people. So while Alpine and its 6,000 people get covered, other populations endure shortages in care.

“We’ve got a physician shortage any way you look at it,” said Floyd, the JPS Health Network official.

Texas ranks 47th among U.S. states for the number of active primary care physicians per 100,000 people, according to the Association of American Medical College’s 2011 state physician workforce report. Fewer than 18,000 primary care physicians serve Texas’ population of more than 25 million people, 3.5 million of which live in rural areas.

“Probably the biggest hurdle we have as a rural health care clinic is bringing people out here,” Gonzalez said.

Toward healthier finances

A fifth-generation resident of Fort Stockton, Gonzalez said he knew he’d have trouble attracting doctors to desolate West Texas. A CEO out of water with a mergers-and-acquisitions attitude of “not growing is dying,” settling down at Cactus Health Services could have been a death sentence.

“There is an innate problem in the United States with FQHCs, that some of these FQs have been around for years and years and years and have become comfortable,” Gonzalez said. “Basically they’re stuck on the government teat and they can’t operate without that.”

Federally qualified health centers operate on government grants. In fact, they have to get government money to become one. But all that money can lead to dependency.

The health reform bill appropriated close to $5 billion for the health centers this fiscal year and will continue to give billions more in the future as long as the cost of treating patients rises and the centers keep increasing their patient loads.

Gonzalez considers the merger a step in the right direction, away from pushing paperwork for more government money and actually expanding Cactus Health Services into a sustainable business.

Texas has 64 federally qualified health centers that operate another 337 service delivery sites, according to a study by the Kaiser Foundation. That’s second to California with 118. And it will likely keep growing.

“[Billings’] has got tons of potential growth because the government is so focused on helping the FQs,” Gonzalez said. “I just think what needs to happen is the FQs just have to get a stronger and a better model.”

And Billings is growing. He’s now paying a grant writer $12,000 to apply for a $500,000 government grant to buy one of the houses for sale behind the clinic and open Alpine’s first dentist’s office to accept Medicare patients.

Billings might say everything that’s happened since moving to Alpine is still part of his boyhood dream to be a small-town doctor. But where he finds himself today is only 10 years in the making from the moment he and his wife, Susan, honeymooned in Fort Stockton.

He told her about his loan-repayment plan and moving to a small town. He asked her to pick three towns where she would be willing to move. Alpine, Marfa and Marathon were her choices.

Making a life as a small-town doctor wasn’t easy on him or his family. Missing two of Blake’s birthdays hit particularly hard.

“Those two instances really kind of kicked me below the belt and I thought, ‘You know, this stinks,’” Billings said. “I’m really happy to be here and helping deliver a baby, but I sure feel like I’m missing something important back home.”

For Billings, the realities of small-town life brought into focus what mattered most to him.

“Someday I’ll be replaced as a physician,” he said. “It’s inevitable, and my patients may miss me for the first couple of weeks to months to years, but eventually I’ll just be, ‘Oh yeah, that doctor that was here. What was his name?’ And I can be replaced as a husband. My wife could divorce me and marry somebody else. And I don’t want to be, but I could never be replaced as a father.”

Staff writer Peggy Heinkel-Wolfe contributed to this report.

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